Charting "Incidents"

[Bug Out, BSN]

How detailed does everyone chart when there are incidents (falls, pt accusations etc.)?

I had a patient c/o someone being "rude" and borderline neglectful and abusive. I called the DON for advice on how to approach the subject, of course her cellphone was off so I left a message and continued to chart the conversation and how the pt described this individual and the action I took.

Fast forward several days and I get a phone call basically saying I did bad by charting the event. I was told not to chart anything related to "incidents" and notify the DON so that they can "investigate." If something comes out of the investigation then "they" will chart on the incident.

This would mean that basically I would not have a say in my involvement nor would it look like I took action plus someone else would be back charting on an event that I was primarily involved with.

I have heard that this is standard practice in most facilities but this sounds more like they are attempting to protect the company vs the RN...am I correct in this or way off base?

So...should I chart incidents in detail or be vage or just leave it alone entirely?

[eltrip]

see your pm box

[caliotter3]

I see it the way you presented it in your post.

[Mulan]

Chart what you need to chart to CYA.

[Southern Fried RN]

In my facility, if a patient falls then it is documented in the notes. Just the facts---patient assessment, doctor notified, xrays, etc. One thing we are told NOT to do is chart "incident report filed." The rationale from risk management is that a lawyer can use that as a way to view internal hospital incident reports that they may not want the lawyers to see.

If it is an "incident" that a patient is accusing another nurse of something, it needs to be reported to risk management. If it doesn't pertain to the patient's reason for admission, assessment, plan of care then it doesn't go in the medical record. The nurses note is NOT the place to write a blow by blow of another nurse and a patient's complaint about the nurse.

However, this is not to say that a patient accusing a nurse of being neglectful/abusive should be ignored. In fact, it is a good idea to write all of that down, word for word what the patient said. Report it to risk management right away--just put it on a separate sheet of paper. The best example from my experience I can give is a patient saying a nurse sexually assaulted her when she was awakening from anesthesia. Obviously that is pretty serious and risk management came down to investigate. The nurse who cared for the patient did not document what she said in the medical chart but put it in an internal incident report. Risk manangement was very upfront with the patient and family that they were looking into it, so it's not like not putting it into the medical chart something was trying to be concealed.

Believe me--I understand the need to CYA. Just be careful about WHERE you choose to CYA lest you get in hot water over the wrong place. Hopefully someone with more legal nursing advice will chime in here.

[Orca, ADN, ASN, RN]

As a rule of thumb, if a patient tells me something I use a verbatim quote if possible, without any judgment of whether the patient is telling the truth. I would include behavior that is out of whack with the information being presented (for instance, in the situation you mentioned if the patient was laughing while relating that someone had been rude and abusive, that would be worth noting). Stick to what you see and hear without trying to interpret it - just the facts.

One thing we are told NOT to do is chart "incident report filed."

This is a legal matter. Incident reports are not discoverable in court proceedings - unless their existence is mentioned on documents that are. You could open the door to big problems by alluding to an incident report in your charting. Something that was never meant to be public information could become public very quickly.

[Bug Out, BSN]

Well if I do not mention an incident report and do not chart the incident in the pt's chart then where does the jury see that I took the incident serious, documented my observations, and took action?

I am worried that if Mrs Joe Blow makes an accusation and I only document it in an internal document then it would appear from outside that I kept an accusation secret and took no furthur action to resolve the issue.

[Orca, ADN, ASN, RN]

I didn't say not to chart anything about the incident. Just don't go into the level of detail that you would in an incident report, or mention that an incident report exists. As far as a jury taking your response seriously - I believe that you're assuming a level of knowledge of internal reporting procedures that the jury is not likely to have.